Please complete and print two copies of this form. One copy should go to your instructor, the second copy should be
kept for your records.
Service Learning Contract
Student Last Name: ______________________________________________ First Name: _______________________________
Phone: __________________________________________ Email: ___________________________________________________
Address: ___________________________________________________________________________________________________
City: __________________________________________________________ State: ___________ ZIP: ____________________
Instructor Name: ___________________________________________________________________________________________
Course Name and Number: __________________________________________________________________________________
Agency Name: __________________________________________ Site Supervisor: ___________________________________
Starting Date: ___________________________________________ Ending Date: _____________________________________
Days and Hours of Service: _______________________________________________________ Hours per week: ___________
Learning Objectives
Why did you select this service learning site?
What do you hope to learn throughout the semester through the service learning experience?
Describe the types of service or volunteer work you will be doing at the site.
Required Signatures
I agree to commit to the above named organization for the duration of the semester. If I am unable to attend my
scheduled time for any reason, I agree to contact my site supervisor ahead of time to let them know of my absence.
Student Signature: ____________________________________________________ Date: _____________________________
Supervisor at the site acknowledges service work is being done for course credit and has talked with the student about
their learning objectives. Will provide the normal training and supervision provided for any service.
Site Supervisor Signature: _____________________________________________ Date: _____________________________
Instructor acknowledges all of above as meeting the requirements as specified in the syllabus.
Instructor Signature: __________________________________________________ Date: _____________________________
College of DuPage
Career Services
3258 Student Services Center (SSC)
CARSERV-14-16831(R9/14)
